I really think that when you post a bunch of percentages that you should at least
try to reference a study. As much as I believe that you are an expert, I'd rather see some proof.
A 90% (
at best as you stated) 1-year patency rate is very low for current stents and unlikely to be accurate. If it is true,
I want to read the study. Also,
5-year data supporting CABG would be more supportive of your argument, and 5-year morbidity and mortality (compared to a 1-year) would be more relevent to surgical intervention as well, as traditionally the less invasive procedures fare better in the immediate post-operative time period.
Old data shows CABG to have a significantly higher
event free survival (lower number of reinterventions) at 5 years, but no statistically significant advantage on overall survival, and this is with bare metal stents. (ARTS II trial).
What is troubling to CT surgeons is that most of the data that they quote that is in favor of CABG over PCI is based on the use of bare-metal stents, which is outdated since most stenting is now done with drug-eluting stents. The new stents have decreased stenosis rates and therefore decreased number of reinterventions.
Now, don't get me wrong: I would love for CABG to remain as an important treatment for CAD, but to say that "surgery is the
best solution for LAD disease" is near-sighted, as patient population, degree of stenosis, comorbidities, etc play a large role in determining which treatment is best.
Also, the vessel that we as surgeons are holding onto tightly is not the LAD, but the
left main, as CABG is still the standard of care for left main disease.....of course, there are trials currently underway by cardiologists whose preliminary data shows left main stenting to be safe and effective.
I'm personally torn emotionally by the issue. I love CT surgery and want there to be a strong future for the field, but it's
unfair to the patient to be upset that less invasive procedures are being shown to be equally effective and, in some instances, superior.
The future of CT surgery is largely dependent on the creation of "hybrid procedures" as you mentioned, as well as the ability of CT surgeons to gain privileges to perform percutaneous interventions. And, of course, we always have the diabetics........
I do agree with you, however, that the IMA kicks @ss.
Some literature to read if interested:
1. The BARI trial. N Engl J Med 1996; 335: 217-224.
2. ARTS I and II trials. 1-N Eng J Med 2001; 344:1117-24. 2-J Am Coll Cardiol 2005; 46:575-81.
3. Argument against PCI: N Eng J Med 2005; 352:2174-83.
4. Drug eluting stents: 1. N Eng J Med 2003; 349:1315. 2. N Eng J Med 2004: 350: 221.
